Thursday, May 7, 2009

Hammer and a different nail: Brucellosis??

In 2005 a 39 year old female developed tingling and weakness of the right leg. She subsequently developed an unusual burning pain of the left flank. Weakness spread to both legs followed by the onset of fatigue. A community neurologist diagnosed MS. She went to NIH for further evaluation. Three lesions were seen in the brain MRI and she was begun on MS therapy with Avonex. Despite therapy the burning sensations persisted and were quite severe and difficult to manage. She went on to develop tachycardia and anxiety. She required treatment with beta blockers, anti-anxiety drugs and analgesics. This was a year into her syndrome. She subsequently developed ringing in the ears(tinnitus). MS flare ups with burning and weakness were treated with IV steroids with some improvement. A Lyme WB showed a 41 band and she was briefly treated with doxycycline with no improvement. Now, nearly 2 years into the illness, she developed cholecystitis. Symptoms of leg weakness, burning and tremors worsened. The brain MRI was stable. The MS therapy was ineffective. Over several months she developed memory loss and increasing fatigue. Courses of IV steroids prescribed by neurologists seemed to exacerbate things. I convinced her to have an evaluation to exclude LD. The WB showed a nonspecific banding pattern and the urine antigen capture test was negative. Over the next year she became more profoundly tired. I thought everything fit with Lyme. I was determined to prove she had Lyme disease. I was unable to do so. Despite negative test results, more antibiotics were tried without much improvement. She progressed to develop diffuse joint pains.

Then she had an episode of profound weakness and went to the hospital ER. A serological test for Brucellosis was positive, but she was told it was a false positive. She developed cranial nerve signs and had persistent, worsening signs of peripheral neuropathy Two years ago I put her on Doxy and Rifampin, therapies for Brucellosis. She then moved out of state and was lost to follow up. Recently she came back to the area. She is still being treated for MS. She recalls that the antibiotics helped but she only took them for several weeks. Now, at age 43, she has weakness, migraines and profound fatigue. She has been hospitalized for MS exacerbations and treated with steroids on several occasions. She has developed progressive neurological impairments typically associated with MS. Her anxiety has increased and she takes tranquilizers at an increased dose.

A Brucella IgM antibody by EIA, obtained a few days ago shows a positive IgM. The IgG is negative.

A quick review of literature shows that the debate regarding chronic Brucellosis has been ongoing for decades, before anyone had heard the words Lyme disease.

It turns out that chronic Brucellosis has been thought to be associated with non specific symptoms including: joint pain, muscle pain, neurological disease and neuro-psychiatric symptoms. Brucella is a small, inracellular gram negative bacteria. Like other such organisms, it has mechanisms for eluding the innate and acquired immune defenses. According to Harrison's textbook of medicine, significant neurological disease requires 6 to 12 months of antibiotics, typically with Rocephin. But of course, the existence of chronic, post treatment Brucellosis is controversial. It is suggested that malingering, obesity and alcohol abuse need to be excluded.

This patient is not native to the US. She grew up in a part of the world where Brucella is known to be endemic.

Do you think it would work to do a period of Rocephin followed by Omnicef and Probenicid to continue progress (maybe with Rifampin added) as you suggested for neuro Lyme in your later post? For example, 3 months of IV Rocephin followed by Omnicef/Probenicid if the patient has stabilized? I am curious if you think this would be effective for neurobrucellosis too.

Also, aren't brucellosis tests fairly useless too, or are there good ways to measure it, especially in its chronic form?

I hope you'll do a follow up blog on this since there isn't much info. out there. Thanks for doing this post!